Respiratory assessment.txt

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Respiratory assessment.txt
2015-05-26 18:42:58
Respiratory assessment

Respiratory assessment
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  1. 1. How would the nurse assess the rate and rhythm of breathing?
    • By observation and palpation of the chest wall. Hold patients arm over chest and right after counting pulse cunt respirations without patient knowing. You need to get rate and depth of breathing. Observe a full inspiration and expiration.
  2. 2. What would the nurse be looking for during inspection of the thorax?
    The nurse is looking for any lung or respiratory impairment or diformaties in the chest which will indicate a respiratory issue.
  3. 3. What are the landmarks of the chest and thorax used to identify findings and perform
    • assessment? (posterior, lateral & anterior)
    • Nipples, angle of Louis, suprasternal notch, costal angle, clavicles and vertebrae
  4. 4. What is the order followed when palpating and auscultating the lungs?
    • 1-Inspection
    • 2-Palpation
    • 3-Percussion
    • 4-Auscultation
  5. 5. How would the nurse palpate for tactile fremitus (vibrations in chest wall during speech)?
    • Place the palmar surface of fingers or ulnar part of hand over symmetrical intercostal spaces, beginning at lung apex and using a firm light touch.
    • Ask patient to say “ninety-nine” or “one-one-one”.
    • Palpate both sides simultaneously and symmetrically from top to bottom for comparison or use one hand, quickly alternating between sides.
    • Normally a faint vibration is present with speech.
    • If fremitus is faint ask patient to speal louder o lower tone.
    • Normally fremitus is symmetrical.
    • Vibrations strongest at top.
  6. 6. What part of the stethoscope would the nurse utilize when assessing lung sounds?
  7. 7. Where would the nurse locate normal breath sounds?
    • Vesticular: over periphery of lung (except over scapula)
    • Bronchial: Over trachea
    • Bronchovesicular: posteriorly between scapulae and anteriorly over bronchioles lateral to sternum at 1st and 2nd intercostal space
  8. 8. What causes these normal breath sounds?
    • Vesicular: air moving through smaller airways
    • Bronchial: air moving though trachea close to chest wall
    • Bronchovesicular: air moving through large airways
  9. 9. What is the cause and character of adventitious breath sounds?
    • Crackles (Rales):
    • -popping sounds, vary in pitch/intensity
    • -more obvious on inspiration
    • -cause= delayed opening of deflated airways
    • -nor cleared with coughing
    • Rhonchi:
    • -loud , low pitched rumbling bubbly sounds
    • -heard on inspiration or expiration; clear with coughing
    • -cause= thick secretions blocking airways; muscular spasms; new growth or external pressure causing turbulene
    • Wheeze:
    • -continuous high pitched musical/high pitched violins
    • -heard on expiration (sometimes inspiration)
    • -cause= narrowed/obstructed airway
    • Pleural friction rub:
    • -grating sound/leather rubbing together
    • -best heard on inspiration
    • -does not clear with coughing
    • -cause= inflamed pleural membranes rubbing together
  10. 10. Where would each of these adventitious breath sounds be located?
    • Crackles: most common in dependent lobes; right and left lung bases
    • Rhonchi: over trachea and bronchi; if loud enough, able to her over most lung fields
    • Wheeze: over all lung fields
    • Pleural friction rub: over anterior lateral lung field (if patent is sitting upright)